Original Research Focus on Suicide October 26, 2021

Effects of Electroconvulsive Therapy on Suicidal Behavior and Emergency Department Use Among Homeless Veterans: A Propensity Score–Matched Study

Jack Tsai, PhD; Talya Peltzman, MPH; Bradley V. Watts, MD, MPH; Brian Shiner, MD, MPH

J Clin Psychiatry 2021;82(6):21m13935

ABSTRACT

Objective: This study examined the effects of electroconvulsive therapy (ECT) on suicidal ideation, suicide attempt, and emergency department use among homeless veterans receiving services in the Veterans Affairs (VA) health care system.

Methods: National VA administrative data from 2001 to 2017 were analyzed using propensity score matching to compare 1,524 homeless veterans who received ECT and 3,025 homeless veterans discharged from psychiatric inpatient units serving as matched controls.

Results: Homeless veterans who received ECT were significantly less likely to have used any ED services 30 and 90 days after their first ECT session compared to homeless veterans who did not receive ECT (OR = 0.65, 95% CI = 0.60–0.71; OR = 0.86, 95% CI = 0.81–0.93, respectively). Homeless veterans who received ECT showed reductions in suicidal ideation and suicide attempts after ECT, but these reductions were significantly less than homeless veterans who did not receive ECT 30 days, 90 days, and 1 year later (OR = 1.48–2.00).

Conclusions: ECT has the potential to reduce ED use among homeless veterans with ECT-responsive psychiatric conditions. Further study is needed on whether the treatment engagement required of ECT participants indirectly reduces use of acute services in this population.

Continue Reading...

Did you know members enjoy unlimited free PDF downloads as part of their subscription? Subscribe today for instant access to this article and our entire library in your preferred format. Alternatively, you can purchase the PDF of this article individually.

Subscribe Now

Already a member? Login

Purchase PDF for $40

Members enjoy free PDF downloads on all articles. Join today

  1. Tsai J, Doran KM, Rosenheck RA. When health insurance is not a factor: national comparison of homeless and nonhomeless US veterans who use Veterans Affairs Emergency Departments. Am J Public Health. 2013;103(suppl 2):S225–S231. PubMed CrossRef
  2. Tsai J, Rosenheck RA. Risk factors for ED use among homeless veterans. Am J Emerg Med. 2013;31(5):855–858. PubMed CrossRef
  3. Redelmeier DA, Molin JP, Tibshirani RJ. A randomised trial of compassionate care for the homeless in an emergency department. Lancet. 1995;345(8958):1131–1134. PubMed CrossRef
  4. Han B, Wells BL. Inappropriate emergency department visits and use of the Health Care for the Homeless Program services by homeless adults in the northeastern United States. J Public Health Manag Pract. 2003;9(6):530–537. PubMed CrossRef
  5. Tsai J, Szymkowiak D, Kertesz SG. Top 10 presenting diagnoses of homeless veterans seeking care at emergency departments. Am J Emerg Med. 2021;45:17–22, 22. PubMed CrossRef
  6. Szymkowiak D, Montgomery AE, Johnson EE, et al. Persistent super-utilization of acute care services among subgroups of veterans experiencing homelessness. Med Care. 2017;55(10):893–900. PubMed CrossRef
  7. Tsai J, Szymkowiak D, Radhakrishnan R. Antipsychotic medication prescriptions for homeless and unstably housed veterans in the Veterans Affairs health care system. J Clin Psychiatry. 2020;82(1):20m13372. PubMed CrossRef
  8. Hermes E, Rosenheck R. Psychopharmacologic services for homeless veterans: comparing psychotropic prescription fills among homeless and non-homeless veterans with serious mental illness. Community Ment Health J. 2016;52(2):142–147. PubMed CrossRef
  9. American Psychiatric Association. The Practice of Electroconvulsive Therapy Recommendations for Treatment, Training, and Privileging: Task Force Report of the American Psychiatric Association. 2nd edition. Washington, DC: American Psychiatric Association; 2001.
  10. Weiner RD, Reti IM. Key updates in the clinical application of electroconvulsive therapy. Int Rev Psychiatry. 2017;29(2):54–62. PubMed CrossRef
  11. Husain MM, Rush AJ, Fink M, et al. Speed of response and remission in major depressive disorder with acute electroconvulsive therapy (ECT): a Consortium for Research in ECT (CORE) report. J Clin Psychiatry. 2004;65(4):485–491. PubMed CrossRef
  12. Medda P, Perugi G, Zanello S, et al. Response to ECT in bipolar I, bipolar II and unipolar depression. J Affect Disord. 2009;118(1–3):55–59. PubMed CrossRef
  13. Petrides G, Fink M, Husain MM, et al. ECT remission rates in psychotic versus nonpsychotic depressed patients: a report from CORE. J ECT. 2001;17(4):244–253. PubMed CrossRef
  14. Kho KH, van Vreeswijk MF, Simpson S, et al. A meta-analysis of electroconvulsive therapy efficacy in depression. J ECT. 2003;19(3):139–147. PubMed CrossRef
  15. Case BG, Bertollo DN, Laska EM, et al. Declining use of electroconvulsive therapy in United States general hospitals. Biol Psychiatry. 2013;73(2):119–126. PubMed CrossRef
  16. Sackeim HA. Modern electroconvulsive therapy: vastly improved yet greatly underused. JAMA Psychiatry. 2017;74(8):779–780. PubMed CrossRef
  17. Wilkinson ST, Agbese E, Leslie DL, et al. Identifying recipients of electroconvulsive therapy: data from privately insured Americans. Psychiatr Serv. 2018;69(5):542–548. PubMed CrossRef
  18. Gelenberg AJ, Freeman MP, Markowitz JC, et al; Work Group on Major Depressive Disorder. Practice Guideline for the Treatment of Patients With Major Depressive Disorder. 3rd ed. Arlington, VA: American Psychiatric Association; 2010.
  19. Kellner CH, Fink M, Knapp R, et al. Relief of expressed suicidal intent by ECT: a consortium for research in ECT study. Am J Psychiatry. 2005;162(5):977–982. PubMed CrossRef
  20. Ahmadi N, Moss L, Simon E, et al. Efficacy and long-term clinical outcome of comorbid posttraumatic stress disorder and major depressive disorder after electroconvulsive therapy. Depress Anxiety. 2016;33(7):640–647. PubMed CrossRef
  21. Avery D, Winokur G. Suicide, attempted suicide, and relapse rates in depression. Arch Gen Psychiatry. 1978;35(6):749–753. PubMed CrossRef
  22. Dennis NM, Dennis PA, Shafer A, et al. Electroconvulsive therapy and all-cause mortality in Texas, 1998–2013. J ECT. 2017;33(1):22–25. PubMed CrossRef
  23. Liang CS, Chung CH, Ho PS, et al. Superior anti-suicidal effects of electroconvulsive therapy in unipolar disorder and bipolar depression. Bipolar Disord. 2018;20(6):539–546. PubMed CrossRef
  24. Peltzman T, Shiner B, Watts BV. Effects of electroconvulsive therapy on short-term suicide mortality in a risk-matched patient population. J ECT. 2020;36(3):187–192. PubMed CrossRef
  25. Watts BV, Peltzman T, Shiner B. Mortality electroconvulsive therapy [published online ahead of print June 24, 2021]. Br J Psychiatry. 2021. CrossRef
  26. Shiner B, Peltzman T, Cornelius SL, et al. Recent trends in the rural-urban suicide disparity among veterans using VA health care. J Behav Med. 2021;44(4):492–506. PubMed CrossRef
  27. Elixhauser A, Steiner C, Harris DR, et al. Comorbidity measures for use with administrative data. Med Care. 1998;36(1):8–27. PubMed CrossRef
  28. Hoffmire C, Stephens B, Morley S, et al. VA Suicide Prevention Applications Network: a national health care system-based suicide event tracking system. Public Health Rep. 2016;131(6):816–821. PubMed CrossRef
  29. Guidance on the use of electroconvulsive therapy. National Institute for Health and Care Excellence. 2009. Cited April 7, 2021. https://www.nice.org.uk/guidance/ta59/chapter/3-the-technology
  30. Sackeim HA, Aaronson ST, Bunker MT, et al. The assessment of resistance to antidepressant treatment: rationale for the Antidepressant Treatment History Form: Short Form (ATHF-SF). J Psychiatr Res. 2019;113:125–136. PubMed CrossRef
  31. Hunter CE, Palepu A, Farrell S, et al. Barriers to prescription medication adherence among homeless and vulnerably housed adults in three Canadian cities. J Prim Care Community Health. 2015;6(3):154–161. PubMed CrossRef
  32. Coe AB, Moczygemba LR, Gatewood SBS, et al. Medication adherence challenges among patients experiencing homelessness in a behavioral health clinic. Res Social Adm Pharm. 2015;11(3):e110–e120. PubMed CrossRef
  33. Peltzman T, Gottlieb DJ, Shiner B, et al. Electroconvulsive therapy in Veterans Health Administration hospitals: prevalence, patterns of use, and patient characteristics. J ECT. 2020;36(2):130–136. PubMed CrossRef
  34. Tsai J, Cao X. Association between suicide attempts and homelessness in a population-based sample of US veterans and non-veterans. J Epidemiol Community Health. 2019;73(4):346–352. PubMed CrossRef
  35. Hoffberg AS, Spitzer E, Mackelprang JL, et al. Suicidal self‐directed violence among homeless US veterans: a systematic review. Suicide Life Threat Behav. 2018;48(4):481–498. PubMed CrossRef
  36. Tsai J, Trevisan L, Huang M, et al. Addressing veteran homelessness to prevent veteran suicides. Psychiatr Serv. 2018;69(8):935–937. PubMed CrossRef